Minding the Baby in the Bathwater: setting a research agenda for global mental health

Pamela Y. Collins, MD, MPH National Institute of Mental Health

February 27, 2015

HOW DO WE MAKE AN IMPACT?

National Institutes of Health (NIH) & National Institute of Mental Health (NIMH)

• NIH is a part of the US Department of Health and Human

Services and is the nation’s medical research agency

• Leading supporter of medical research in the world

• NIMH is one of the 27 institutes & centers that make up the National Institutes of Health (NIH)

Mission: To transform the understanding and treatment

of mental illnesses through basic and clinical research, paving the way for prevention,

recovery, and cure.

NIMH

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NIMH Offices and Divisions

• Office on AIDS

• Office of Autism Research Coordination

• Office of Constituency Relations and Public

Liaison

• Office of Genomics Research Coordination

• Office for Research on Disparities and Global

Mental Health

• Office of Resource Management

• Office of Rural Mental Health Research

• Office of Science Policy, Planning, and

Communications

• Office of Technology Development and

Coordination

• Division of Intramural Research

Programs

• Division of Neuroscience and Basic

Behavioral Science

• Division of Translational Research

Division of Services and Intervention

Research

• Division of AIDS Research

• Division of Extramural Activities

Office of the Director NIMH Divisions

ORDGMH & ORMHR

Admin

Workforce Diversity

Equity & Disparities

Global Mental Health

Women’s Mental Health

Rural Mental Health REPORTING

& ANALYSIS RESEARCH

CAPACITY BUILDING

OUTREACH & COLLABORATION

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Guided by NIMH Strategic Plan • Strategic Objective 1: Define the Mechanisms of

Complex Behaviors

• Strategic Objective 2: Chart Mental Illness Trajectories to Determine When, Where, and How to Intervene

• Strategic Objective 3: Strive for Prevention and Cures

• Strategic Objective 4: Strengthen the Public Health Impact of NIMH-supported Research

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http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml

Adapting to a Changing Ecosystem

• Increasing Public Health Burden • BRAIN Initiative • Changing Mental Health Care

Landscape • Technology • Comparative Effectiveness • New Sources of Research Support

and Collaboration • Citizen-centered Science

NIMH Strategic Plan Adaptation to Change and Cross-cutting Themes

http://www.nimh.nih.gov/about/strategic-planning-reports/introduction.shtml#intro-sub1

Cross-cutting Research Themes

• Transforming Diagnostics

• Accelerating Therapeutics

• Role of the Environment

• Digital Enterprise

• Preemptive Medicine

• Global Mental Health

• Mental Health Disparities

• Partnerships

• Investing in the Future

Outreach & Collaboration: HHS

Resolution- WHO Executive Board

Resolution – World Health Assembly

Comments on draft document

Regional consultation process

ACTION PLAN! 9

Understanding the systems in which we operate

Health financing

Health workforce

Mental health

services

Global mental health operates within the global health system

Set an agenda

Allocate resources

Research and develop new ideas

Implement & deliver services

Monitor, evaluate, learn

Moon et al. PLoS Med 2010

HOW ARE WE DOING?

Vos et al, 2012

GLOBAL GAME CHANGERS

“HIV prevention and treatment scale-up during the first decade of the 21st century qualifies as a game changer that has irreversibly changed

perceptions of and approaches to global health.”

De Cock et al, 2011

Radical innovations that fundamentally change how something is done, thought about, or

approached.

RESEARCH & INNOVATION….and more • Rapid development and scale up of

innovations – Rapid HIV tests – Early infant diagnostic tests

• Willingness to change when new evidence appears – Incorporate new activities into

longstanding programs – Quick and coordinated changing

of antiretroviral drug regimens • Targeted funding, “unorthodox” partnerships (CBOs, gov, civil society, professional societies) De Cock et al 2011

What determines whether a problem achieves prominence on the agenda ? • Transnational influences

– Norm promotion – Resource provision

• Domestic advocacy

– Policy community cohesion – Political entrepreneurship – Credible indicators – Focusing events – Clear policy alternatives

• National political environment

– Political transitions – Competing health priorities

Shiffman AJPH 2007

A few key factors

• The policy community and its portrayal of the issue – How credible and how salient are the messages?

• Problem and solution claims

– What can be done?

• What institutions can this community build? – Critical to keeping the issue on the agenda

See Shiffman, WHO Bull 2009

“The rise, persistence and decline of a global health issue may best be

explained by the way in which its policy community – the network of

individuals and organizations concerned with the problem – comes to understand and portray the issue and establishes institutions that can

sustain this portrayal.” Shiffman 2009

Global mental health stakeholders

• People with mental illness • Families affected by mental illness • Researchers/academics • Mental health professionals • Professional associations • Advocacy organizations • Funders • Policymakers

The central variable is the frame –the way an issue is understood and portrayed.

Shiffman, 2009

Disabling Disorders of Youth

Vos et al, 2012

Percentage of years lived with a disability in 2010 by cause and age.

Male individuals Female individuals

Mental disorders are ubiquitous

Vos et al, 2012

Mortality and the Global Burden of Mental Disorders

• People with mental disorders have a mortality rate that is 2.2 times higher than the general population

• All cause mortality was elevated for psychoses, mood disorders, and anxiety

• All cause mortality for psychoses > anxiety, depression, and bipolar d/o

• Median of 10 years of potential life lost from all causes

• 8 million deaths a year are attributable to mental disorders Walker et al. JAMA Psychiatry, 2015

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Millennium Development Goals and mental health: a salient frame

GOAL 5: REDUCE MATERNAL MORTALITY

Miranda & Patel, 2004

GOAL 4: REDUCE CHILD MORTALITY

GOAL 6: Combat HIV/AIDS, Malaria, and other Diseases

Problem claims: Costly disorders

“The global cost of mental health conditions in 2010 was estimated at US$ 2.5 trillion, with the cost projected to surge to US$ 6.0 trillion by 2030 .”

“Currently, high-income countries shoulder about 65% of the burden, which is

not expected to change over the next 20 years.”

World Economic Forum, 2011

Problem claims: Poor mental health financing

Globally, spending on mental health is less than $2 per person, per year and less than $0.25 in low income countries Mental health expenditures per capita are more than 200 times greater in high income countries compared with low income countries

WHO Atlas, 2011

Finding solutions around the globe: Task shifting/sharing for mental health

• Good examples in many low- and middle-income countries – India – MANAS trial (Patel et al., 2010) – Pakistan – Lady Health Workers ( Rahman et al, 2008) – Uganda – Group IPT for depression (Bolton et al, 2003) – Chile – Treating depression in primary care (Araya et al, 2003)

Institutions for Global Mental Health

• Movement for Global Mental Health • Global Mental Health Journal • World Federation for Mental Health • World Psychiatric Association • -Considerable variability in the “norms and

strategies” adopted by our institutions

Is Global Mental Health (GMH) on the Agenda?

• Institutions – GMH institutions are insufficient

• Ideas – Difficult to develop and promote a common construct – Lack a widely accepted framework for classification,

course, treatment of disorders – No distinction between internal and external debates

Tomlinson & Lund 2012

Is Global Mental Health on the Agenda?

• Context – Can we take advantage of key opportunities to

influence decision makers?

• Framing our problem – Do we have credible indicators? – How can we better demonstrate salience?

Tomlinson & Lund, 2012

What is the role of research?

--Creating transnational norms --Credible solutions for national health systems --Building the evidence for salience

Grand Challenges in Chronic Non-communicable Diseases

Daar et al, 2007

NIMH-GACD Collaboration

• NIMH joined the Global Alliance for Chronic Disease in November 2009

• The Alliance is a community of the world’s largest health research funding agencies organized to collaborate in the battle against chronic non-communicable diseases

• Mental health is on the agenda • NIMH is leading the Grand Challenges in Global Mental

Health initiative

• Global Scope • Use of the Delphi process • Covers the full range of mental, neurological,

and substance use disorders • Aims to build a community of global mental

health research funders

What’s new in the Grand Challenges?

Goodman, 1987

• Establish leadership structures • Nomination of Delphi Panel • 3 Delphi Rounds • Leadership meeting • Preparation and publishing of report

Overview of Procedures

• Three discrete leadership bodies are responsible for the stewardship of the initiative • Executive Committee • Scientific Advisory Board • Administrative Board

GCGMH Leadership

Grand Challenges in Global Mental Health 7 JULY 2011 | VOL 475 | NATURE

Grand Challenge Goals

• Goal A: Identify root causes, risk, and protective factors

• Goal B: Advance prevention and implementation of early interventions

• Goal C: Improve treatments and expand access to care

• Goal D: Raise awareness of the global burden

• Goal E: Build human resource capacity

• Goal F: Transform health system and policy responses

Credible solutions for national health systems

Goal: Research directions to reduce the treatment gap in low- and middle-

income countries

Addressing the Gaps

Questions – What research is needed

to reduce the treatment gap?

– Which stakeholders

need to interact to produce service-relevant research? Scale up?

Participants

NGOs providing Services

Mental Health Policymakers

Implementation researchers

COLLABORTIVE HUBS FOR INTERNATIONAL RESEARCH ON MENTAL HEALTH (U19)

-Research component on task-shifting -Research capacity-building for the region -True collaborative partnerships with end-users

AFFIRM hub South Africa*, Ethiopia, Ghana, Malawi, Uganda, Zimbabwe

SHARE hub India*, Pakistan, Afghanistan, Bangladesh, Nepal, Sri Lanka

LATIN-MH hub Brazil*, Peru, Colombia, Ecuador Guatemala

Pam-D hub Nigeria*, South Africa, Kenya, Ghana, Liberia,

Collaborative Hubs for International Research on Mental Health

RedeAmericas hub Chile*, Brazil, Argentina, Colombia, USA

RedeAmericas • Improving the health of people

with psychosis

• Research mentoring for young investigators

• Critical Time Intervention – Task-Shifting

• Peer mentors assist people new to treatment with links to health care and community resources

www.nimh.nih.gov

South Asian Hub for Advocacy, Research & Education (SHARE) on Mental Health

• Mental health of mothers with depression

• Research capacity-building

• Thinking Healthy Program – Peer Delivery

• Delivery by peers – lay people with no formal health training background

www.nimh.nih.gov

Africa Focus on Intervention Research for Mental Health (AFFIRM)

• Maternal depression in South Africa

• Community care for schizophrenia in Ethiopia

• Short courses, Master’s program

• Task-shifting to community health workers/primary health workers

http://www.nimh.nih.gov/about/organization/od/globalhubs/africa-focus-on-intervention- research-for-mental-health-affirm.shtml; http://www.affirm.uct.ac.za/

Partnership for Mental Health Development in sub-Saharan Africa (PAM-D)

• Expanding service for people with psychosis

• Research capacity-building through targeted training and mentoring

• Exploring complementary and alternative providers

http://www.nimh.nih.gov/about/organization/od/globalhubs/ partnership-for-mental-health- development-in-sub-saharan-africa-pam-d.shtml

Latin America Treatment and Innovation Network in Mental Health (LATIN-MH)

• Research capacity-building

• Managing co-morbid depression and hypertension or diabetes

• Low-intensity psycho-educational intervention delivered via smartphones

http://www.nimh.nih.gov/about/organization/gmh/globalhubs/ latin-america-treatment-amp-innovation-network-in-mental-health-latin-mh.shtml

Building Salience The Grand Challenge of Integration

Mental health and HIV

• Increasing attention to integrated care

• Transnational norms

• Little evidence base on how to integrate care outside of high-income countries

Integrating mental health: a Grand Challenge

• Healthy Options: Group psychotherapy for HIV+ depressed perinatal women – Tanzania

• Integrated care for co-morbid diabetes and depression in India

• The depression hypertension COACH study – China

• Integrating depression care for acute coronary syndrome patients in low resource hospitals

in China • COBALT: Co-morbid Affective disorders,

HIV/AIDS and Long-term Health – South Africa

• Improving mental health through integration with primary care in rural Karnataka - India

PLoS Medicine series 2013

What’s next?

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